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A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen.
The life of a patient diagnosed with diabetes is complicated.
“Treating diabetes is not simple,” says Gregory J. Deines, DO, division chief, Diabetes & Endocrinology of Spectrum Health Hospitals in Grand Rapids, Michigan. “It involves a complex medication regimen.”
About 30 million Americans have diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Published studies estimate between 38% and 93% of those patients are noncompliant with their treatment regimen. “It is a significant number, no matter which end of the range,” says Patricia L. Bononi, MD, medical director for the Center for Diabetes at Allegheny Health Network in Pittsburgh.
Often, patients see their treatment as too difficult, too expensive or interfering with their daily activities. “There is a lot of work associated with having diabetes,” Bononi stresses.
One of the biggest issues with diabetes is that patients usually don’t feel any symptoms until they experience a medical event, such as a heart attack or stroke, says Jason Bhan, MD, co-founder and chief medical officer of Prognos, which applies artificial intelligence (AI) to clinical lab diagnostics.
“Until then, there is little or no consequence for their behavior,” he notes. “As long as patients don’t feel like they need to take something, there is a whole list of reasons for them to not take their medications.”
But compliance is a medical necessity. The key is to create a setting where patients understand complying with their treatment plan is necessary to their health, but providers understand the variables that stop patients from being in compliance. To create such a setting, providers have developed team-based care solutions that examine medical and nonmedical conditions that prevent compliance.
A team of experts
A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen, providers say. The team can be comprised of endocrinologists, pharmacists, dieticians, social workers, educators, and behavioral health specialists. Each specialist uses their skills to discover the motivations of a patient. By fostering a one-on-one relationship with patients, and not just telling them what they should do, the chances of compliance increase.
“It’s important to think in terms of a team approach, even for physicians who may not be blessed with a complex [healthcare] system,” says Edward Dick, MD, senior vice president of Integrated Health Services at Methodist Healthcare Ministries in San Antonio, Texas. “They need to develop a team within the community and with payers.”
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Methodist Healthcare Ministries sees patients at two San Antonio clinics, many of whom are at 200% of the federal poverty level and lack insurance. Often, a diagnosis of diabetes is incidental to why a patient originally sought treatment.
Patients at this income level face a number of self-determinant challenges, Dick says. For example, getting to an appointment might be difficult because of issues related to a job, transportation or childcare.
“That’s why we have the [different] specialists offer as many services as possible during one visit,” Dick says. “We try to find alternative means of education to make sure patients can actually achieve their goals. The team has to recognize that patients have their own priorities, and those priorities are not always the same as physicians.”
Allegheny Health Network’s team evaluates patients during a 12-week period at a diabetes specialty center. Not only are there medical tests, but the team addresses obstacles that might prevent an improvement in treatment compliance, Bononi says. Moreover, the team provides quality metrics and education and serves as a resource to primary care practices.
“Since primary care is where the vast majority of patients receive their diabetes care, it’s important that they can access education there,” Bononi says. “And it’s important that the staff has the knowledge to help coach patients.” In Grand Rapids, Deines says one issue is that patients simply can’t take their medications every day-whether the reason is cost, quality of life issues, or other variables. So, the team tries to get to know and understand the personal circumstance of patients, as well as their desired outcomes and goals.
“Once you understand what motivates and drives your patients’ decisions, you can better partner with them,” Deines notes. “We can employ resources to help with issues like income, beliefs, or ideas about certain treatments.”
While it’s a medical fact that hitting certain blood pressure and blood glucose numbers are critical for long-term health, sometimes patients are simply concerned with enjoying their favorite hobby unimpeded by possible side effects, Deines says. “The healthcare team must understand the patient’s complete situation,” he maintains.
Trending in the right direction
The multidisciplinary approach has had a positive impact on many patients. “They come to our clinic, and they tell us it’s the first time anyone asked about their goals and what’s important to them,” Deines says. “The outcomes are much improved.”
Some patients come to a Methodist Healthcare Ministries clinic and tests reveal an A1c level of 13% (The target A1c level for individuals with diabetes is usually less than 7%). Normally, these patients would immediately start on a regimen that includes several medications and intensive lifestyle changes, Dick says. But working with patients individually, some choose to start on only metformin. In some instances, lifestyle changes and metformin can reduce A1c levels significantly.
“Thanks to the hard work of our patients and care team, our diabetes outcome measures are trending favorably,” Dick says. “But we know there is much more work to be done.”
Allegheny Health Network’s initiatives have paid dividends, especially in the area of education. Bononi says she was surprised by a statistic that indicated 31% of prescriptions written for diabetes are never filled. Expense is one reason; another is patients don’t like to take more medications than they feel are necessary. They’re also skeptical about the medication’s efficacy or have concerns about side effects.
“That’s where our pharmacists have helped us,” she says. “They do a great job of explaining how the medications work, and why they are beneficial.”
In 2018, Prognos conducted extensive research on a subset of its patient population diagnosed with diabetes, examining patients prescribed first-line medication therapy-either or both metformin and sulfonylureas-during the first half of 2017 and were on no prior medications during the previous year.
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While not examining compliance and noncompliance, Bhan says care managers can use the research to motivate noncompliant patients into taking their medications and maintaining a healthier lifestyle more regularly.
“If just 20% to 25% of patients can be moved from non-adherence to adherence by educating and engaging them, that’s a huge number in savings and morbidity,” Bhan stresses. “It’s much easier to engage patients around hard facts versus hypotheticals.”
The patient population with better control of their diabetes utilizes less resources, including emergency department visits and hospitalizations, and have fewer rates of complications, such as end-stage renal and cardiovascular disease.
“Patients want to live their lives as close to normal without their treatment getting in the way,” Deines says. “We have to partner with patients so they can achieve that goal. But we have to help patients understand they can better achieve that goal if they adhere to their treatment plan.”
Ken Krizner is a freelance writer based in Cleveland, Ohio.